Treatment of recurrent Clostridium difficile infection: a systematic review

Background

Clostridium difficile infection (CDI) recurs in nearly one-third of patients who develop an initial infection. Recurrent CDI (RCDI) is associated with considerable morbidity, mortality, and cost. Treatment for RCDI has not been not well examined.

Methods

A systematic review.

Results

Sixty-four articles were identified evaluating eight different treatment approaches: metronidazole, vancomycin, fidaxomicin, nitazoxanide, rifampin, immunoglobulins, probiotics, and fecal bacteriotherapy. The meta-analysis found vancomycin to have a similar efficacy to metronidazole, although studies used varying doses and durations of therapy. Fidaxomicin was slightly more efficacious than vancomycin, though the number of studies was small. Good evidence for probiotics was limited. Fecal bacteriotherapy was found to be highly efficacious in a single randomized trial.

Conclusion

Metronidazole and vancomycin have good evidence for use in RCDI but heterogeneity in treatment duration and dose precludes robust conclusions. Fidaxomicin may have a role in treatment, but evidence is limited to subgroup analyses. Fecal bacteriotherapy was the most efficacious. Saccharomyces boulardii may have a role as adjunctive treatment.     

Fungal osteoarticular infections in patients treated at a comprehensive cancer centre: a 10-year retrospective review

This study reviewed retrospectively the clinical characteristics of 28 cancer patients with fungal osteoarticular infections (FOAIs) between 1995 and 2005. Most patients (26; 93%) had haematological malignancies (19 had leukaemia); half (14) were allogeneic stem-cell transplant recipients. Twelve patients (43%) had severe neutropenia (< or = 100/mm3) with a mean duration of 65 days (range 10-500 days), and ten (36%) patients had received a significant dose of corticosteroids. Most (19; 68%) FOAIs were caused by contiguous extension, while nine (32%) were associated with haematogenous spread. Pain, joint instability and local drainage were seen in 28 (100%), six (21%), and seven (25%) patients, respectively. Sixteen (57%) patients had symptoms for < 1 month. The sinuses (ten; 36%) and the vertebral spine (six; 21%) were the most common sites involved. Moulds were the predominant pathogens: Aspergillus fumigatus (two); non-fumigatus Aspergillus spp. (eight); non-specified Aspergillus spp. (three); Fusarium spp. (six); Zygomycetes (five); Scedosporium apiospermum (two); and Exserohilum sp. (one). Candida was the causative pathogen in four cases (including two cases of mixed FOAIs). Arthritis and post-operative FOAIs were both uncommon manifestations, occurring in two patients each. All patients received systemic antifungal therapy (combinations in 20 cases), and 19 cases underwent adjunctive surgery. The crude mortality rates (at 12 weeks) were 44% (9/20) in the patients who underwent surgery and antifungal therapy vs. 33% (2/6) in patients who received antifungal therapy alone (p not significant). FOAI is a rare, yet severe, manifestation of localised or systemic mycoses, caused predominantly by moulds, and is seen typically in patients with haematological malignancies.     

Antimicrobial susceptibility of 128 Salmonella enterica serovar typhi and paratyphi A isolates from northern India

Most systemic Salmonella enterica serovar typhi and paratyphi A infections diagnosed in the United States (up to 70%) are acquired during travel to regions of high endemicity. Increasing resistance to agents commonly used for the treatment of such infections (including multidrug resistant isolates) is being reported from several areas of the world (Southeast Asia, Africa, Latin America). Since regional differences in susceptibility patterns may exist, we sought to determine the frequency of antimicrobial resistance among blood and stool isolates (n = 128) from patients in Northwestern India. Salmonella enterica serotype typhi (n = 101) isolates from 14 patients were susceptible to all agents tested. Among 55 isolates with single drug resistance, 44 (81%) were resistant to chloramphenicol. Multidrug resistant (>/=3 drugs) Salmonella enterica was more common in pediatric patients (10 of 30) compared to adults (10 of 71 patients; p = 0.05). All isolates (S. enterica serovar typhi and serovar paratyphi A) were susceptible to ciprofloxacin and ceftriaxone. Travelers to Northwestern India may still receive trimethoprim-sulfamethoxazole, or ciprofloxacin for effective chemoprophylaxis if indicated. Ceftriaxone and ciprofloxacin remain favorable choices for treatment of patients with enteric fever in this region.     

Tenofovir therapy for lamivudine resistance following liver transplantation

BACKGROUND: Resistant hepatitis B virus (HBV) strains develop in 30% of liver transplant recipients treated with lamivudine within 2 years from the time of transplantation. OBJECTIVE: To assess safety and outcomes of tenofovir salvage therapy for patients with lamivudine resistance in a retrospective cohort of liver-transplanted patients. METHODS: Medical records were retrospectively evaluated for patients who received tenofovir. Data collected included demographics, HBV serologic information prior to and during tenofovir therapy, drug-related complications, and creatinine clearance. Criteria for lamivudine resistance included elevation of liver chemistries along with reappearance of hepatitis B surface antigen, hepatitis Be antigen, and/or HBV DNA. RESULTS: Sixteen patients showed resistance to lamivudine at 10-85 months (median 26) following liver transplantation. Tenofovir 300 mg/day orally was added in 8 patients 1-66 months after the development of viral lamivudine resistance and continued for 14-26 months (median 19.3). All 8 patients experienced HBV DNA viral suppression, with 7 currently nondetectable. No adverse events were reported, and creatinine clearance was not impaired. CONCLUSIONS: Our results suggest that tenofovir safely and markedly decreases replication of lamivudine-resistant HBV variants after liver transplantation and is another potential option for the treatment of HBV lamivudine resistance.     

Decline in the incidence of neural tube defects after the national fortification of flour (1997-2005)

OBJECTIVE: To evaluate the effect of flour fortification with folic acid on the incidence of neural tube defects (NTDs) in babies. We also report the pattern of NTDs, and we compare it with those reported previously. METHODS: All babies who were born with NTDs at King Abdul-Aziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia between 1997 and 2005 were included in the study. The incidence of NTDs was compared between the eras before flour fortification (1997-2000) and the eras after fortification. RESULTS: We have observed a decline in NTD incidence in the last decade from 1.9/1000 live births (1997-2000) to 0.76/1000 live births (2001-2005). Forty-two babies were born with NTDs with a male to female ratio of 1.1:1. Sixty percent received folic acid during pregnancy, but none pre-conception. Eighty-three percent of the cases had myelomeningocele (MMC), 12% had encephalocele, 2.5% had meningocele, and another 2.5% had anencephaly. Ninety-one percent of MMC patients had severe physical disability. Thirty-two children (91%) had hydrocephalus, which required shunting in the neonatal period and 22 children (63%) had clubfeet. CONCLUSION: After folic acid flour fortification, there was an apparent decline in the incidence of NTDs in babies born at KAUH. However, the incidence is still high and associated with serious morbidity. This stresses the need for innovative programs to increase folic acid consumption by women of childbearing age, to reduce NTDs.